Combining Thyroidectomy with Cardiac Surgery: Implications for the Endocrine Surgeon

Abstract

The management of incidentally detected retrosternal goiter in patients with cardiac disease awaiting open heart surgery is controversial. Here, we present the case of a 79-year-old man; who had coronary artery bypass grafting, aortic valve replacement and thyroidectomy for retrosternal goiter under a single anesthetic. A literature search was conducted to study patient demographics, thyroid symptomatology, pathology, complications and the risks and benefits of the combined procedures. Literature search revealed only a few similar cases of a combined surgical approach and these are from the perspective of the cardiac surgeon. The study is presented to highlight the implications of such combined procedures for the endocrine surgeon.A medline search was conducted for combined procedures on heart and thyroid. Five case reports and two reviews, including one case of off-pump coronary artery bypass grafting (CABG) was obtained. The mean age of the patients was 69 years (range, 55-79). Retrosternal goiter was the commonest indication (67%), half of them presenting with tracheal compression. Thyrotoxicosis was observed in 22%. Beinign multinodular goiter was the commonest pathology (89%). There was one case of Grave's disease. There were no reported malignancies. There were no reported complications from the endocrine surgery.The various cardiac procedures in the combined operations were coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, a combination of these and a case of closure of atrial septal defect.The review has looked into the anatomical and physiological implications of combined operations, operative risks and has upheld the safety of such combined procedures.

Perioperative management of combined coronary bypass surgery and thyroidectomy

“…To the best of our knowledge, combined surgery for goiter and CAD has only been reported by a few researchers in the literature. [1][2][3] In all of these cases, thyroidectomy was performed first, with combination of collar incision and median sternotomy; however, in our case, off-pump CABG surgery was performed first and followed by thyroidectomy after heparin neutralization. Wexler et al [4] have suggested that thyroidectomy should be done before anticoagulation for CABG to minimize risk of bleeding.…”

“…Doing thyroidectomy after cardiac surgery raises the cumulative risk for the two separate operations, whereas performing it before cardiac surgery may increase cardiac risk as result of anesthesia. [1,2]…”